Pulmonology Coding Alert

Voluntary termination of procedure by the patient does not count.

When your pulmonologist curtails or terminates a procedure, do you know exactly when you can use modifier 52 (Reduced services) or modifier 53 (Discontinued procedure)? Our real-world examples demonstrate when to report these modifiers so you can recoup the just rewards for your provided services.

Get the Difference Between Reduced and Failed

You will use modifier 52 “to indicate the service was provided as described by the CPT® code description but not fully,” says Laureen Jandroep, CPC, CPC-H, CPC-I, CPPM, CMSCS, CHCI, founder and CEO at CodingCertification.org in Oceanville, N.J. “It usually indicates the fee should be reduced by the payer.”

For example: A patient is mechanically ventilated and the pulmonologist performs a bronchoscopy through an endotracheal tube to verify the tube’s placement above the carina. No inspection of the mainstream bronchi or the more distal airways is performed precluding a full diagnostic bronchoscopy. In such a case, you should report 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic,with cell washing, when performed [separate procedure]) with modifier 52 as only a tracheoscopy was performed.

Be sure that the documentation is adequate to justify the procedure indication, the underlying condition(s), and the extent of the completed procedure. Documentation will be requested to review these details for medical necessity of the service and corresponding payment.

Modifier 52 Comes in Handy When a Procedure Falls Short

You can also use this modifier to indicate a service that wassignificantly less than usually required to fit the code descriptor.

Example: A sleep lab monitors and records a patient for seven hours during a polysomnography. The patient is unable to sleep and only four hours of useable data is recorded. As the polysomnography test requires six or more hours continuous monitoring, the pulmonologist would report the service with 95810 (Polysomnography; age 6 years or older, sleep staging with four or more additional parameters of sleep, attended by a technologist) appended by the professional component with modifier 26 (Professional component) and the reduced component with modifier 52 (Reduced service) to a second charge of 95810.

Tackle Stopped or Terminated Procedures With 53

When you append a procedure code with modifier 53 n(Discontinued procedure), you are telling the payer that the doctor could not complete the procedure because the patient’s health and well-being are at risk.

Example: Your pulmonologist prepares a patient for a bronchoscopy with topical anesthesia. The physician administers moderate sedation and begins the procedure. However, midway through the procedure, the patient’s oxygen saturation falls and the physician decides to stop the procedure and reverse the sedation. You should report this encounter with 31622 and a modifier 53.

Watch out: You can’t use this modifier when the physician elects to cancel the procedure or service related to the patient’s condition prior to its initiation. In fact, CMS states that modifier 53 “is not used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite.”

Check Note for Complete Details

No matter what modifier you use for which situation, payers will need to see thorough notes explaining why the service ended.

“In the case of either modifier 52 or 53, the documentation needs to reflect the circumstances that necessitated reducing or discontinuing the procedure,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians in Leawood, Kan. “Most importantly, do not reduce your charge for the service. The payer will request to review the documentation prior to reimbursing the service, and they will determine the extent of payment,” adds Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania.